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Running head: OBSESSIVE-COMPULSIVE 1
Obsessive-Compulsive Disorder
Name
Liberty University
Author Note
Correspondence pertaining to the content of this article should be directed to Name,
Department of , Liberty University, Lynchburg, VA 24515-0002
E-mail:
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Abstract
Obsessive-compulsive disorder consists of either obsessions, compulsions, or both
simultaneously. This disorder has oscillated through many different classifications throughout the
various DSM editions but now exists within a category of its own in the most recent edition.
Behavior once deemed as odd/eccentric or just a religiously troubled soul gradually has become
understood as a psychological disorder in which people are vexed by intrusive thoughts and
actions they feel as if they must complete. While the true cause of this disorder was unknown for
a long time, modern psychology has tied the basis of the disorder to biological dysfunction in
areas of the brain including the frontal cortex, basal ganglia, and thalamus. Neurological
problems in these areas combined with rigid and negative cognitive impulses appear to result in a
disorder in which people feel compelled to do certain actions, usually in certain repetitions or to
obsess over certain ideas. While this disorder may be frustrating to live with, there are promising
new drug and behavioral treatments that have proven effective in regulating mood along and
reducing both obsessions and compulsions. These treatment approaches combined with a biblical
worldview offer a well-rounded approach to helping people live with and handle obsessive-
compulsive disorder.
Key Words: obsessions, compulsions, anxiety, history, SSRIs, exposure and relapse prevention,
biological causes, religion, culture, coping, stress, OCD
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Obsessive-Compulsive Disorder
Introduction
Obsessive-compulsive disorder (OCD) has gone through several different classifications
as an understanding of the disorder developed. The DSM-IV categorized OCD as an anxiety
disorder in which obsessions or compulsions were present. Upon further consideration, the
DSM-5 edition decided to place OCD within a category of its own and made it possible to be
diagnosed with either obsessions, compulsions, or both (SAMHSA, 2016). According to the
DSM-5, people are diagnosed with obsessions if they (1) have persistent/recurring thoughts or
images that are unwanted and cause them anxiety and (2) try to ignore the thought or quell the
anxiety with another thought or action (compulsion). The DSM-5 defines compulsive behavior as
repetitive physical or mental actions that follow a rigid set of self-imposed rules that a person
feels forced to perform to satisfy their anxiety or obsession. These compulsions must be coupled
with the fact that the acts performed are excessive or not realistic ways of nullifying the situation
that they are intended to pacify (SAMHSA, 2016). Additional DSM-5 criteria for compulsions
include the fact they are time-consuming or interfere with daily living, and the disturbances are
not better characterized by another disorder or some form of substance abuse (SAMHSA, 2016).
These kinds of obsessions and compulsions are demanding and will not be satisfied until the
action or thought is complete. This kind of rigid behavior can be debilitating in one’s overall
quality of life.
Historical Context
OCD appears to show in recorded histories as early as the 15th century. People of this time were
never labeled with OCD, but their obsession with combating malevolent spirits with some form
of ritualistic behavior resembles several of the characteristics of OCD (Nicolini et al., 2017).
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However, some texts describing religious behaviors of Christians, Muslims, and Jew tracing back
as far as the 7th century depict different types of obsessive behaviors and extreme anxiousness
that also align with OCD behavior. During this time, anyone with OCD was viewed as a religious
fanatic. Many people with OCD were considered insane until the 1850s when psychology
became a more explored field of study and classified OCD behavior as neuroses (Nicolini et al.,
2017). In the 1880s the popular psychological theory about OCD attributed the disorder to a loss
of self-control and personal will as one’s ability to regulate emotions declined. Common
characteristics of OCD such as perfectionism, rigidity, and discomfort with affection were
ignored so the diagnosis remained as a form of neurotic behavior in the DMS-I (Nicolini et al.,
2017). Later issues reallocated OCD as just another characteristic feature of anxiety disorder.
Identification of the neurological causes of OCD such as the corticostriatal circuits and the
amygdala in 1987 by L.R. Baxter and associates broadened the perspective on many of the
psychological disorders previously listed within the DSM. As more connections were made
between neurological causations and OCD behavior, anxiety was proven to not be an adequate
classification (Nicolini et al., 2017). Recent acknowledgment of OCD having co-morbidities
with disorders such as anxiety and depression has been a monumental progression for the
disorder as the DSM-5 now recognizes OCD as a separate classification
Causes of OCD
New biological research into the brain suggests OCD is a result of neurological
misfunctioning of the corticostriatal-thalamocortical (CSTC) circuitry. The CSTC is part of the
salient network of the brain which exercises cognitive control over the stimuli response
inhibition and selection. The salient network has primary control over attention control,
motivation, cognition, and motor movement. Through this control, the salient network makes
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cognitive and behavioral decisions for the body (Peters et al., 2016). While there is still
uncertainty about the complete causation of OCD, it is believed that the orbitofrontal-subcortical
loops of the basal ganglia circuitry of the CSTC is hyperactive and over stimulates the neural
network (Ting & Feng, 2011). More specifically, hyperactivation through the basal ganglia of the
brain triggers hyperactivation within the orbitofrontal cortex, thalamus, anterior cingulate, and
striatum. This hyperactivation may be caused by serotonin because selective serotonin reuptake
inhibitors (SSRIs) lowered the metabolic activity observed in these areas of the brain in children
with OCD (Seibell & Hollander, 2014). Due to the high neurological disruption observed in
OCD patients, research suggests there is a genetic component as well that is the cause for
serotonin hyper activating the CSTC. Typical familial studies suggest first degree relatives have
a 7-15% chance of having OCD, suggesting some form of shared genes. The main gene of focus
has been the 5-HTTLPR serotonin transporter (Nestadt et al., 2010). Short versions of the 5-
HTTLPR serotonin transporter lead to a reduced amount of serotonin released by the brain,
which appears to allow the brain to get stuck in a state of activity. Other studies also implicate
excessive release of glutamate over stimulating the brain, adding to its heightened state of
activity. Combined, low serotonin levels and high glutamate levels have been implicated in the
production of obsessions and compulsions (Maia & Cano-Colino, 2015). Because there appear to
be significant neurological causes there are several promising drug treatments that can be
coupled with therapy to improve the daily lives of people with OCD.
OCD Treatments
OCD now has a multitude of treatment options between medications, different types of
therapy, and a combination of both together. Some of the most common drug therapies include
SSRIs. SNRIs, and tricyclics. The SSRIs block the reuptake of serotonin at the neuronal synapse,
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prolonging the presence of serotonin in the neural network and allowing for less activation of the
CSTC. SSRIs are the main form of drug treatment and have proven to be the most effective when
given in high doses. The most common SSRI prescribed for people with OCD is fluvoxamine
(Pittenger & Bloch, 2014). SNRIs have shown promise as well, but there is apprehension about
using SNRIs as the sole drug for treatment due to insufficient research. Tricyclics such as
clomipramine also inhibit the reuptake of serotonin because it has such a high binding affinity to
multiple receptor sites, inadvertently blocking serotonin’s reuptake. Tricyclics are mood
enhancers that also deal with OCD co-morbidities such as depression and anxiety and appear to
have stronger relief effects with OCD. However, SSRIs are the preferred drug for OCD because
the side-effects of the tricyclics such as weight gain, hypotension, and sedation are more adverse
(Pittenger & Bloch, 2014). Additional forms of treatment include therapy. Amongst all different
approaches, cognitive-behavioral therapy has proved to be the most consistently effective. People
with OCD undergo a series of habituation where there are exposed to trigger stimuli that evoke
obsessions and/or compulsions, then they work through the anxiety to avoid completing their
soothing compulsion. After several attempts, the brain will realize completing the compulsion or
having the obsession is not necessary. The cognitive aspect of the treatment also challenges the
thinker’s view on compulsions, making him/her realize that nothing bad will happen if the
compulsion is not completed (Ponniah et al., 2013). The main goal of therapy is to show the
patient that the impending anxiety they feel towards their obsessions that drives them to
compulsions is neurologically self-imposed and no true consequence will ensue. This type of
therapy coupled with drugs that combat neurological imbalances show great improvement in
patient lives. However, there is still a great need for further research to pinpoint more effective
drug therapies with fewer side effects and more positive, long-lasting results.
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Prevention
Unfortunately, there has been no evidence that OCD can be prevented. The disorder
shows strong biological causes that are not easily prevented. Some preventative measures to
avoid making OCD worse usually comes with education and surprisingly, reduction of family
compliance. Usually, families will overlook or ignore obsessive-compulsive behaviors, but if
they are taught to not comply with the loved one's compulsions, there is a reduction in
habituation of compulsive behavior (Brakoulias et al., 2018). If the compulsive habits that ease
OCD patient anxieties never form, patients may be more likely to avoid OCD behaviors.
Prevention of OCD occurring is quite difficult however, so there has been a focus on reducing
obsessive-compulsive behaviors and preventing relapses. SSRIs are a common biological form
of treatment that has been shown to reduce obsessions and compulsions, but it is not always
effective or an indefinite cure. Usually, drug therapy combined with exposure therapy produces
positive results. A similar approach called exposure and response prevention therapy (ERP) has
also shown promise in almost eliminating OCD. ERP focuses on a graduated exposure scale
where patients are asked to rank their triggers then gradually work through physical or mental
exposure to the stimulus without giving in to their compulsion. This may include not washing
their hands after touching things they deem as ‘dirty’ or not counting to a certain number while
performing a ritualized task (Hezel &Simpson, 2019). Eventually, patients learn to cope with
increasingly more adverse tasks. The main goals of this treatment are to extinguish the patient's
illogical fears and break the responsive habits of compulsions. New successful improvements to
ERP include attention bias, in which the patient distracts himself during exposure therapy, so
they did not focus on inflammatory words or ideas that would worsen their condition. This new
addition only proved useful however when coupled to ERP therapy (Hezel &Simpson, 2019).
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The response prevention part of ERP therapy focuses on preventing patient relapse so they can
live an obsession/compulsion-free life. The cognitive-behavioral approach of this therapy
disproves patient's preconceived notions of fear and breaks the ritualistic response habits that
they have conditioned themselves with because it once used to decrease their stress towards a
situation. If patients no longer fear their triggers and have healthy coping mechanisms, they will
not engage in their obsessions or compulsions. This form of therapy has proven to be 50%
effective among all OCD patient participants, especially when coupled with drug therapy (Hezel
&Simpson, 2019). The relapse prevention training shows a lot of promise in eliminating the
debilitating nature of OCD, however, it is still not consistently effective or entirely generalizable
with the whole OCD patient population, so better forms of preventative and long term treatment
are still needed (Wheaton et al., 2015).
Cross-Cultural Perspective
Recent studies have shown a different prevalence in the degree of obsessions, the severity
of compulsions, and co-morbidities among people from various cultural backgrounds, leading to
the assumption that cultural influences affect the manifestation of OCD. OCD is often induced
and made worse by stress, so cultural approaches towards stress may relieve or increase stress.
Individualistic societies inadvertently create the desire to be perfect, and this is only exacerbated
in people with OCD. Americans with OCD display higher comorbidity of substance abuse, most
likely because of the pressures of culture as well as the collective attitude towards drugs and
alcohol (Nicolini et al., 2017). In contrast, the Latin-American community has a strong collective
culture that encourages people to turn to their families during a problem. However, this type of
attitude may worsen compulsions of OCD patients as familial acceptance of habit-forming
compulsive behaviors has been indicated as a negative trigger for OCD. Indian and African
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American cultures place a great emphasis on religion. People with OCD, especially those who
follow Catholic or Muslim practices, have a greater likelihood of developing religious obsessions
as observed throughout history with early documented cases of OCD (Nicolini et al., 2017).
Catholicism and Islamic worship practices are structured around routine and patterns which can
easily be turned into some form of compulsion. However, religion may also be a place were
people with OCD find peace. Many people in the Indian community will turn to their faith to
cope with their OCD. This difference is quite evident by the number of OCD patients in India
that receive pharmacological treatment. Only about 10% of India’s OCD patients receive some
form of drug therapy, while 100% of Spain, Italy, and Japan’s patients receive drugs or a
combination of drug and behavioral therapy (Nicolini et al., 2017). The discrepancy lies in
India’s approach. Most Indian families would rather seek healing through a religious leader or
form of prayer than address the condition as a biological cause (Nicolini et al., 2017). Every
culture inadvertently affects how OCD patients view themselves, how they will handle stress,
and what ways they seek to cope with or treat their disorder. The cultural aspect of OCD remains
greatly unstudied, however, and serves as a possible area of research in the future.
Biblical View of OCD
When afflicted with any form of health condition, physical or mental, people often turn to
religion for comfort. People find relief when they trust in a higher power and want to find the
peace that comes with letting go of control. Cultures that emphasize spiritual and religious
practices like India have observed that 50% of their patients attribute their OCD to spiritual
causes and seek treatment from a faith healer rather than a medical professional (Nicolini et al.,
2017). For people of faith, explaining and dealing with their disorder may be easier through faith
rather than modern medicine. Many people of faith with OCD often display signs of religious
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obsessions because the disorder makes them want to achieve perfection in faith and spiritual
purity (Agorastos et al., 2014). Finding comfort in faith is always what God intended for us, but
He never demanded perfection. When treating a patient with OCD, using a biblical worldview
approach in conjunction with modern medicine techniques offers a holistic approach to healing
them. 2 Timothy 1:7 reminds us, “For God hath not given us the spirit of fear; but of power, and
of love, and of a sound mind” (KJV). People with OCD need to be shown they are loved even if
they are not perfect, and that there is nothing to fear because God is with them. A biblical
approach reminds those with OCD that they should not live their life in fear or quench their
anxieties with compulsions. Turning to God should help people with OCD, but not give them
another obsession or make their disorder worse. Psychologists treating patients with OCD can
also provide better care to their patients utilizing a biblical approach. Treating mental disorders
can be quite challenging and will always require lots of patience. James 1:5-8 tells us “If any of
you lack wisdom, let him ask of God, that giveth to all [men] liberally, and upbraideth not; and it
shall be given him” (KJV). In times of frustration or doubt about the best forms of treatment,
mental healthcare providers should turn to God and seek those who He provides for guidance
and wisdom.
Conclusion
OCD is a debilitating mental disorder that had been present for hundreds of years and
greatly reduces the quality of people’s lives. Living life in constant worry and anxiety translates
into obsessions and compulsions that force an unhealthy need for rigid perfectionism. Previously
perceived as religious neuroticism and insanity, OCD is finally recognized as a disorder. While
OCD may be similar to anxiety, its causation results from hyperactivity of the basal ganglia
circuitry of the CSTC neural network linked to insufficient amounts of serotonin and over
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secreted glutamine. Through the use of SSRIs and exposure and relapse prevention therapy,
patients may gain normal functioning within their daily lives. Families may also be the key to
preventing the development of OCD by stopping the cycles of obsession and compulsion
appeasement. Unfortunately, there are no completely effective or universal methods of treatment
nor prevention for OCD at this time, presenting an area of possible study in the future. Through
collaboration and patience, a better and more well-rounded approach to OCD patients can be
taken, helping to bring spiritual, physical, and mental peace.
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References
Agorastos, A., Demiralay, C., & Huber, C. G. (2014). Influence of religious aspects and personal
beliefs on psychological behavior: focus on anxiety disorders. Psychology research and
behavior management, 7, 93–101. https://doi.org/10.2147/PRBM.S43666
Brakoulias, V., Perkes, I., Tsalamanios, E. (2018). A call for prevention and early intervention in
obsessive-compulsive disorder. Early Interv Psychiatry.12(4):572-577. doi:
10.1111/eip.12535. Epub 2017 Dec 14.
Hezel, D., Simpson, B. (2019). Exposure and response prevention for obsessive-compulsive
disorder: A review and new directions. Indian journal of psychiatry vol. 61,Suppl 1: S85-
S92. doi:10.4103/psychiatry.IndianJPsychiatry_516_18
Maia, T.V, Cano-Colino, M. (2015). The Role of serotonin in orbitofrontal function and
obsessive-compulsive disorder. Sage Journal. Vol 3(3). Retrieved from:
https://doi.org/10.1177/2167702614566809
Nestadt, G., Grados, M., & Samuels, J. F. (2010). Genetics of obsessive-compulsive disorder.
The Psychiatric clinics of North America, 33(1), 141–158.
https://doi.org/10.1016/j.psc.2009.11.001
Nicolini, H., Salin-Pascual, R., Cabrera, B., & Lanzagorta, N. (2017). Influence of Culture in
Obsessive-compulsive Disorder and Its Treatment. Current psychiatry reviews, 13(4),
285–292. https://doi.org/10.2174/2211556007666180115105935
Peters, S. K., Dunlop, K., & Downar, J. (2016). Cortico-Striatal-Thalamic Loop Circuits of the
Salience Network: A Central Pathway in Psychiatric Disease and Treatment. Frontiers in
systems neuroscience, 10, 104. https://doi.org/10.3389/fnsys.2016.00104
lOMoARcPSD|268163 03
OBSESSIVE-COMPULSIVE
13
Pittenger, C., & Bloch, M. H. (2014). Pharmacological treatment of obsessive-compulsive
disorder. The Psychiatric clinics of North America, 37(3), 375–391.
https://doi.org/10.1016/j.psc.2014.05.006
Ponniah, K., Magiati, I., & Hollon, S. D. (2013). An update on the efficacy of psychological
therapies in the treatment of obsessive-compulsive disorder in adults. Journal of
obsessive-compulsive and related disorders, 2(2), 207–218.
https://doi.org/10.1016/j.jocrd.2013.02.005
Seibell, P. J., & Hollander, E. (2014). Management of obsessive-compulsive disorder.
F1000prime reports, 6, 68. https://doi.org/10.12703/P6-68
Substance Abuse and Mental Health Administration (SAMHSA). 2016. Impact of the DSM-IV to
DSM-5 Changes on the National Survey on Drug Use and Health. Rockville (MD).
Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t13/
Ting, J. T., & Feng, G. (2011). Neurobiology of obsessive-compulsive disorder: insights into
neural circuitry dysfunction through mouse genetics. Current opinion in neurobiology,
21(6), 842–848. https://doi.org/10.1016/j.conb.2011.04.010
Wheaton, M.G., Schwartz, M.R., Pascucci, O., Simpson, B.H. 2015. Cognitive-behavior therapy
outcomes for obsessive-compulsive disorder: Exposure and response prevention.
Psychiatr Ann. 45:303–7.
